22 Benefits - Occupational Therapy 20% Coinsurance after Deductible - Radiation / Chemotherapy / Respiratory Therapy 20% Coinsurance after Deductible - Dialysis 20% Coinsurance after Deductible - Cardiac Rehabilitation 20% Coinsurance after Deductible - Pulmonary Therapy 20% Coinsurance after Deductible See “Therapy Services” for details on Benefit Maximums. • Prescription Drugs Administered in an Outpatient Facility (other than allergy serum) 20% Coinsurance after Deductible Physical Therapy See “Therapy Services.” Preventive Care No Copayment, Deductible, or Coinsurance Preventive Care for Chronic Conditions (per IRS guidelines) • Medical items, equipment and screenings No Copayment, Deductible, or Coinsurance Please see the “What’s Covered” section for additional detail on IRS guidelines. Prosthetics See “Durable Medical Equipment (DME), Medical Devices and Supplies.” Pulmonary Therapy See “Therapy Services.” Radiation Therapy See “Therapy Services.” Rehabilitation Services Benefits are based on the setting in which Covered Services are received. See “Inpatient Services” and “Therapy Services” for details on Benefit Maximums. Respiratory Therapy See “Therapy Services.” Skilled Nursing Facility See “Inpatient Services.”